P - 35593Building
Inspections
763-572-3604
763-502-4977 FAX
DATE�� \l.L_
SITE ADDRESS�
THIS APPLICANT IS
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
DESCRIBE WORK BEING
SIZE OF [MPROVEMENT_
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
� � I YOUR E-MAIL ADI
�-�`-i �'t� �V L= 1.5 � � r ;
❑ OWNER �'CONTRACTOR
NAME: r '
ADDRESS:1��_
PHONE: 7#:,��— 'T2`S�— �O�
NAME: IJO[� �,. TVL�,r� o�i^
STATE LICENSE # MI�I ��_� ` .
ADDRESS: ��� �2�ITi�- GT
Permit No.'��� �—�. 4�
Received By:
Date Rec'd: � l�
-�� I il L��'/ STATE ML,IZIP,
CERT NIJMBER —
CiTY STATE�ZIP �����-G.
��7G�'R��
�,SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STOR[ES
❑ ADDITION O GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH ROOF ❑ DRAIN TILE
❑ DECK SIDING ❑ OTHER
❑ SWIMMING POOL
❑ NEW HOME CONSTRUCTION ❑ ADDITION
� MAINTENANCE/REPAIR � REMODELING
ROOFING �
NUMBER OF SQUARES �_
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
� Aluminum
❑ Other
❑ HOUSE ONLY
�HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes ❑No LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
HEIGHT
BASEMENT REMODELING SUBMIT:
I . Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION (NCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
I. Site Plan/Survey showing the existing sWctures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Per[nit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
- - SAC Charge
Curb Cut Escrow
Erosion Control
Park Fee
Sewer Main Charge
Total Due
��
$ � �
$ ��c�0
$
$
$
$
$
$ •
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$5.00 (State Licensed Residential Contractors)
$2230 per SAC Unit (Plans to MWCC for determination)
___ ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks pavable to: Citv of Fridlev
Attach
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L PROCESSED
I hereby apply for a building permit and 1 acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit and work is not to start without a permit on site; that the work will be in a ordance with the
approved plan in the case o 11 work w qu viy�v d approval of pla �^7`��
S[GNATURE OF APPLICANT y/�/i PRINT NAME�y�Q r��rA —+' �'I/I I DATE
APPROVAL INSPECTOR SI NAT � / ��